NREMT Paramedic 1.4.12 Exam Questions

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1.

Which of the following are signs/symptoms of beta blocker toxicity? 

Select the 3 answer options which are correct.

  • Coma 

  • Bradycardia 

  • Hypotension 

  • Hyperglycemia 

Beta blockers will interfere with the sympathetic nervous system and result in bradycardia, hypotension, and possibly coma. Hypoglycemia often occurs in beta blocker toxicity, especially in pediatric patients. 

2.

Which of the following are AHA-recommended management principles after a cardiac arrest patient has a return of spontaneous circulation (ROSC)?

Select the three correct answer options.

  • Maintain MAP greater than 65 mm Hg

  • Obtain 12-lead ECG

  • Initiate targeted temperature management (TTM) if comatose 

  • Maintain MAP greater than90 mm Hg 

  • Initiate targeted temperature management (TTM) for all patients

AHA recommendations for post-cardiac arrest care include:

  • Manage the airway: place an ET tube early and use quantitative waveform capnography or capnometry to confirm and monitor endotracheal tube placement
  • Manage respiratory parameters: start 10 breaths/min (1 breath every 6 seconds), SpO2 92% to 98%, PaCO2 of 35 to 45 mm Hg
  • Manage hemodynamic parameters: administer crystalloid and/or vasopressor or inotrope for goal systolic blood pressure of greater than 90 mm Hg or mean arterial pressure (MAP) greater than 65 mm Hg
  • Obtain a 12-lead ECG: if the patient is not following commands, start TTM as soon as possible using a cooling device with a feedback loop. TTM is not indicated for all patients. 

 90 mm Hg would be an ideal target for the patient's systolic BP, not their MAP.

3.

You suspect your adult chest pain patient may be experiencing the onset of a myocardial infarction (MI). Which of the following medical conditions is most likely to mask the severity of the MI by suppressing or altering the normal ST elevation typically seen on an electrocardiogram (ECG)?

  • Left bundle branch block (LBBB)

  • Chronic hypertension

  • Emphysema

  • Pleurisy

Correct answer: Left bundle branch block (LBBB)

Left bundle branch block (LBBB) is a cardiac conduction abnormality that disrupts the normal electrical activity of the heart. This disruption can obscure the typical ECG findings of an MI, including ST elevation, making it difficult to detect the infarction. LBBB is especially significant in patients who present with chest pain, as it can mask key diagnostic ECG changes.

Chronic hypertension does not typically alter the ST elevation during an acute MI, though it can contribute to long-term cardiac damage.

Emphysema, a type of chronic obstructive pulmonary disease (COPD), may cause changes in the chest and lung areas but does not interfere with the specific ST elevation patterns seen in MI.

Pleurisy causes pain from inflammation in the chest wall but does not impact the ST elevation on an ECG during myocardial infarction.

4.

You are called to assist an adult with chest pain. The patient has a cardiac history of two-posterior myocardial infarctions. He is conscious and alert, stating he is having a hard time breathing, and the chest pain worsens when he attempts to lay flat on his back. His skin is pale and hot, while auscultation of his lung sounds reveals mild crackles. He reports the pain worsens on deep inspiration and movement. Based on the patient's history, and signs and symptoms, which of the following should you suspect?

  • Pericarditis

  • Cardiomyopathy

  • Myocardial infarction

  • Unstable angina pectoris

Correct answer: Pericarditis

Pericarditis is inflammation of the pericardium (sac lining the outside of the heart). Pericarditis is most common in men over age fifty with a recent carcinoma or myocardial infarction history. The key finding that separates pericarditis from myocardial infarction is the presence of a fever and chest pain that is localized and changes with movement, breathing, or coughing. The pain is caused by the irritated pericardium rubbing against the opposite serous membrane.

Cardiomyopathy is a condition characterized by a weakened and enlarged heart muscle. Patients often present with dizziness, peripheral edema, bloating, shortness of breath, and irregular palpitations. Patients with cardiomyopathy do not normally present with movement-related chest pain and fever. Patients with myocardial infarction and unstable angina will not present with chest pain that changes with breathing, movement, or coughing. They will also not have the associated fever and pain on chest wall palpation as seen in pericarditis.

5.

 Which of the following tubes would be most appropriate for nasotracheal intubation for an average height and weight adult?

  • Cuffed 6.0–6.5 mm endotracheal tube

  • Uncuffed 6.0–6.5 mm endotracheal tube

  • Cuffed 7–8 mm endotracheal tube

  • Uncuffed 7–8 mm endotracheal tube

Correct answer: Cuffed 6.0–6.5 mm endotracheal tube

At times, nasotracheal intubation may be the preferred method of airway control. This may be the case in patients who have spontaneous respirations, when laryngoscopy is determined too difficult due to anatomy or laryngospasm or when the motion of the cervical spine must be very limited. Conscious patients tolerate a nasal tube better; they cause less tracheal trauma. The best nasal tube for intubating an average height and weight adult would be a tube that is one size smaller than the optimal tube size for endotracheal intubation and cuffed.

When performing nasal intubation, it is important to choose a tube that is cuffed and one size smaller than the optimal endotracheal tube for the patient. Therefore, using an uncuffed tube of any size would not allow the paramedic to seal the air from escaping from around the tube, making the tube useless. 

Using a 7–8 mm cuffed ET tube for nasally intubating an average height and weight adult would likely be too large a diameter to fit into the nostrils without causing unneeded trauma. Remember, the optimal nasal tube is cuffed, and one size smaller than the appropriate endotracheal tube would have been. 

A 7.0–7.5 mm cuffed ET tube is considered the correct size for orotracheal intubation of an average height and weight adult patient.

6.

Which of the following can be used to identify a hazardous material in a transportation incident? 

Select the 2 answer options which are correct.

  • Waybill 

  • Emergency Response Guidebook 

  • NFPA 704 system 

  • Chemtrec

The waybill is carried by the conductor of a train and can be used to identify the materials on board. The Emergency Response Guidebook (ERG) can be used in conjunction with the labels or placards on material being transported to identify the type of materials being carried. 

Chemtrec may be contacted later, but it will not help you identify the material initially. The NFPA 704 system is used to identify hazardous materials at fixed facilities, not transportation incidents.

7.

Which of the following airway devices are indicated for patients who depend on hypoxic drive to breathe?

  • Venturi mask

  • Non-rebreather mask

  • Nasal cannula

  • Simple face mask

Correct answer: Venturi mask

The Venturi mask is a high-flow oxygen entrainment delivery device. It delivers a precise fraction of inspired oxygen at typically low concentrations. It can deliver a precise FiO2 between 25–50 percent. It is used for patients who require specific concentrations, such as COPD patients.

A non-rebreather mask is a high-flow oxygen delivery system. It is designed to deliver 10–15 liters of oxygen per minute at concentrations approaching 100 percent. These masks are not intended for the long-term treatment of hypoxic drive patients. 

A nasal cannula delivers low-concentration oxygen between 20–44 percent and is designed to deliver up to 6 liters per minute. Nasal cannulas are often used but cannot deliver specific concentrations as a Venturi mask can. 

Simple face masks are seldom used today but are capable of delivering 6–10 liters of oxygen per minute. They are not indicated for the long-term treatment of patients who breathe on hypoxic drive.

8.

Continuous Positive Airway Pressure (CPAP) is used in the management of patients with acute pulmonary edema. Which of the following would be contraindications for using CPAP? 

Select the 2 answer choices that are correct. 

  • Patient is unable to protect their own airway

  • History of recent upper GI surgery 

  • Respiratory distress after a recent submersion incident

  • Respiratory rate is rapid 

Continuous Positive Airway Pressure (CPAP) provides pressure to keep alveoli open and reverse atelectasis caused by pulmonary edema. If a patient is unable to maintain their own airway, had recent upper GI surgery, has altered mental status, hypotension, a closed head injury, or signs of a pneumothorax, CPAP would be contraindicated. 

Patients with respiratory distress after a recent submersion incident may be experiencing pulmonary edema and would benefit from CPAP if they do not exhibit any contraindications. Patients who need CPAP commonly have rapid respiratory rates, so it is not a contraindication. 

9.

Which of the following correctly correlates hemorrhage class with % of blood loss?  

Select the two answer options which are correct.

  • Class I = Less than 15% blood loss

  • Class III = 30–40% blood loss 

  • Class IV 20–40% blood loss

  • Class II 30–40% blood loss 

Classifying hemorrhage will help the paramedic decide on how aggressive to manage fluid resuscitation and anticipate the severity of shock. 

  • Class I = < 15% blood loss
  • Class II = 15-30% blood loss
  • Class III = 30-40% blood loss
  • Class IV = > 40% blood loss 

10.

If considering the administration of magnesium sulfate to a pregnant patient for preeclampsia, what other medication should the paramedic have close at hand during the intervention?

  • Calcium gluconate

  • Diazepam

  • Sodium bicarbonate

  • Pitocin

Correct answer: Calcium gluconate

Calcium gluconate is the antidote for hypermagnesemia caused by the administration of magnesium sulfate. Hypermagnesemia is rare, but in the case of a pregnant patient, it is best to be prepared for the possibility.

Diazepam is not an antidote for the administration of magnesium sulfate. However, it is sometimes given to patients with preeclampsia to suppress seizure activity. 

Sodium bicarbonate is indicated for acidosis conditions or some toxicological emergencies. It is not used in the management of preeclampsia. 

Pitocin is not considered an emergency medication for the treatment of preeclampsia; it is administered to induce uterine contractions.

11.

Chemical suicide often involves mixing common household substances in an enclosed space. This can result in the release of which of the following gases?

Select the 2 answer options which are correct.

  • Hydrogen sulfide 

  • Hydrogen cyanide 

  • Carbon monoxide 

  • Anhydrous ammonia 

Chemical suicide often involves mixing common household substances like detergents and cleaning products in an enclosed space, which can result in the release of hydrogen cyanide and hydrogen sulfide.

Carbon monoxide is a result of combustion and would be seen in suicides where an engine is left running in an enclosed space. Anhydrous ammonia is found in fertilizers and is used in the illegal manufacturing of methamphetamine.

12.

Identify the following rhythm.

  • Junctional tachycardia

  • Ventricular tachycardia

  • Atrial tachycardia

  • Premature ventricular contraction

Correct answer: Junctional tachycardia 

Junctional tachycardia is characterized by a rapid heart rate with indiscernible P waves. Unlike supraventricular tachycardia, where the P waves hide in the T wave, the P waves in junctional tachycardia will be found hiding in the QRS complex. There are no p-waves in front of the QRS complex because the beat is generated at the AV node. However, there might be inverted P-waves due to retrograde conduction; this occurs when the impulse fires from the AV junction and back towards the atria. 

13.

Which heart valve is located between the right ventricle and the pulmonary artery?

  • Pulmonic valve

  • Aortic valve

  • Tricuspid valve

  • Mitral valve 

Correct answer: Pulmonic valve

The pulmonic valve is located between the right ventricle and the pulmonary artery. It is a semilunar valve that separates a ventricle from an artery.

The aortic valve is located between the aorta and the left ventricle.

The tricuspid valve is located between the right atrium and right ventricle.

The mitral valve is located between the left atrium and left ventricle.

14.

You are called to the scene where a 36-year-old male was shot in the back while running away from an assailant. While treating and attempting to stabilize the patient, what should be done with the clothing he was wearing?

  • Place them in a paper bag along with the disposable latex gloves you were wearing when you took or cut the clothing off; seal the bag, listing the items it contains; document the patient's name, time/date, and your name and title on the bag

  • Place them in a plastic evidence bag; do not seal the bag; label it with the time, date, and your name with affiliation; give it to law enforcement on-scene

  • Lay them to the side when they are cut or taken off; notify the officers on-scene to allow them to gather the evidence properly

  • Place all cut or removed clothing between the patient's legs on the stretcher during transport to ensure the items make it to the emergency department where law enforcement will gather them properly

Correct answer: Place them in a paper bag along with the disposable latex gloves you were wearing when you took or cut the clothing off; seal the bag, listing the items it contains; document the patient's name, time/date, and your name and title on the bag

When dealing with a crime scene and a victim, it is best not to touch anything that is not completely necessary to deliver adequate patient care to the victim. If clothing is to be removed that may contain blood or other evidence, it is protocol in most regions of the country for EMS personnel to place the items of clothing in a paper bag; seal the bag; and label it with the time, date, and your credentials.

EMS personnel should not place items of potential evidence in an evidence bag used by law enforcement. Red-tagged evidence bags should only be used by the trained law enforcement handling the scene. This is to avoid any problems with the chain of evidence. Place evidence in a paper bag, and law enforcement will properly process the evidence. 

If items of clothing involved in a crime scene are just left to the side or placed between the victim's legs for law enforcement to gather later, it will likely result in lost evidence. These scenes are so chaotic and fast paced that items often get misplaced or lost if a simple but straightforward method of gathering the evidence is not observed.

15.

Which of the following best describes why hypertensive crises are seldom treated with pharmacological agents in the prehospital setting?

  • If the blood pressure of a hypertensive patient is lowered too quickly, it can cause myocardial infarction, acute renal failure, and/or stroke

  • If the hypertensive patient's blood pressure is lowered too quickly, it can cause pulmonary edema

  • If the hypertensive patient's blood pressure is dropped too quickly, it is likely to cause seizure activity

  • If the hypertensive patient's blood pressure is dropped too quickly, it is most likely to cause bradycardia that worsens brain perfusion

Correct answer: If the blood pressure of a hypertensive patient is lowered too quickly, it can cause myocardial infarction, acute renal failure, and/or stroke

The goal of therapy is controlled but rapid lowering of the hypertensive patient's blood pressure to normalize cerebral blood flow. If the blood pressure is lowered too quickly, infarction of the end organs, such as the heart, kidney, and brain is likely to occur. Therefore, lowering the blood pressure is normally withheld until in the controlled environment of the hospital.

Lowering the hypertensive patient's blood pressure too rapidly is not likely to cause pulmonary edema. 

If the patient's blood pressure is lowered too quickly, it is not as likely to cause seizure activity as if the blood pressure remains excessively high. Hypertension can cause seizures due to decreased brain perfusion. 

Bradycardia is not a concern when lowering the hypertensive patient's blood pressure too quickly. The concern is that lowering the blood pressure too quickly can cause infarction of the end organs such as the heart, kidneys, and brain.

16.

What are ways to calculate the total body surface area (TBSA) of a burn for a pediatric patient?

Select the 3 answer options which are correct.

  • The Lund-Browder chart

  • The rule of nines

  • The rule of palms 

  • Parkland formula 

  • Consensus formula

The rule of nines is a quick way to estimate the TBSA of a burn and is the most widely used by EMS. It divides the body into 11 sections, each representing 9% of the body's surface area. The rule of palms is a fast way to estimate the TBSA of a burn, with 1% TBSA equaling the size of the patient's palm (including fingers). It is more useful for smaller areas or oddly shaped burns but not as accurate for large burns. The Lund-Browder chart is the most accurate way to calculate TBSA, but it is more time-consuming than the rule of nines. It is used more in hospital settings. 

The Consensus and Parkland Formula are used to calculate initial fluid resuscitation for a burned patient, not TBSA. 

17.

Identify the following heart rhythm.

  • Regular rhythm with a pause

  • Regular rhythm with a premature beat

  • Irregular rhythm with a premature beat

  • Regular rhythm

Correct answer: Regular rhythm with a pause

This is a sinus rhythm, with the normal components, that is suddenly interrupted by a pause. The usual cause is first or second degree AV block.

18.

Which of the following are signs/symptoms of pancreatitis? 

Select the three correct answer options.

  • Fever

  • Abdominal pain that radiates to the back 

  • Nausea and vomiting after eating

  • Kehr's sign 

Signs/symptoms of pancreatitis include:

  • Fever
  • Abdominal pain that radiates to the back
  • Nausea and vomiting (particularly after eating)
  • Tachycardia
  • Hypotension
  • Cullen's sign (bruising around the umbilical area due to intraperitoneal hemorrhage) in severe cases

Kehr's sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classic symptom of a ruptured spleen.

19.

Which of the following demonstrates proper care of EKG leads?

  • Examine the cables for broken wires

  • Leave the same electrodes connected to the leads during the day

  • Firmly pull (yank) the electrode leads off of the patient's chest when finished

  • Soak the leads in soapy water at the end of the day

Correct answer: Examine the cables for broken wires 

EKG lead cables must be handled with care to avoid damage. Use caution when clipping and removing electrodes to avoid bending the clips. Always change the electrodes in between patients. While placing the cable in water is not recommended, it is appropriate to use an alcohol wipe to clean the cable.

20.

Identify the following artifact.

  • Toothbrush tachycardia

  • 60 cycle interference

  • Baseline sway

  • Somatic tremor

Correct answer: Toothbrush tachycardia 

Toothbrush tachycardia is caused by a repetitive motion of the arms (such as brushing one's teeth) that affects the rhythm on the EKG. It is similar to ventricular tachycardia and can be mistaken for this at first. Examining the patient, their alert status, and what they are doing, will help you distinguish between the two.